Provider Demographics
NPI:1205331261
Name:SHADRIN, ILYA YEVGENIEVICH (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:ILYA
Middle Name:YEVGENIEVICH
Last Name:SHADRIN
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:ILIA
Other - Middle Name:YEVGENIEVICH
Other - Last Name:SHADRIN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2301 ERWIN RD # DUMC3845
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27705-4699
Mailing Address - Country:US
Mailing Address - Phone:919-684-8111
Mailing Address - Fax:
Practice Address - Street 1:2301 ERWIN RD # DUMC3845
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27705-4699
Practice Address - Country:US
Practice Address - Phone:919-684-8111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC390200000X
MN29209207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine